Acute Pain Management. Difficult Cases. Jeremy Cashman

Transcription

1 Acute Pain Management Difficult Cases Jeremy Cashman

2 Case 1.

3 Brought in to ED at 04:00 having sustained distal femoral & tibial plateau fractures Longstanding chronic severe OA pain Lives in ground floor flat, limited mobility, carer for shopping, meals etc OA pain managed by GP Oral oxycodone IR (OxyNorm ) 40 mg 4 hourly Multiple drug allergies; paracetamol & NSAIDs Initial management in ED Splintage of fractures Referral to T&O for fixation of fractures Acute Pain Service called to 08:00 hrs Oxycodone IR changed to SR, morphine PCA commenced

4 Issues Acute pain management in the ED Acute pain management in opioid dependent patients Opioid use in chronic non-cancer pain (CNCP)

5 Pain Management in the ED ED patients expectations regarding pain relief Much higher than those for postoperative pain Significant pain relief; mean 72% (~18% expect 100% relief) Rapid pain relief; mean expectation for time to analgesic administration 23 min vs actual mean time 78 min Pain protocols in the ED (basically opioid titration regimen) Reduce number of patients with unsatisfactory analgesia from 91% to 69% Increased the use of iv analgesia from 9% to 37% Motov SM, Khan AN. Journal of Pain Research 2009:2:5 11 Goodacre SW, Roden RK. J Accid Emerg Med.1996;13:

6 Pain Management in the ED NHMRC. Emergency Care Acute Pain Manual 2011 Fractures and dislocations For severe pain use iv morphine (or fentanyl) plus paracetamol then consider appropriate nerve or regional block For less sever pain po paracetamol with or without po OxyNorm For procedural analgesia during fracture reduction consider entonox or ketamine with or without midazolam cp135_emergency_acute_pain_management_manual.pdf

7 Acute pain management in opioid dependent patients Acute pain in opioid dependent patients often underestimated and undertreated Consensus recommendations: Maintain regular provision of pre-existing opioid Sustained release formulations Transdermal patches Implantable pumps Additional multimodal analgesia Short-acting opioid (as required); PCA with higher bolus dose shorter lock-out interval Local anaesthesia Adjuvant anti-inflammatory drugs & paracetamol Mehta V, Langford R. Anaesthesia 2006;61: / Reviews in Pain 2009;3: 10-4 Mitra S, Sinatra RS. Anesthesiology 2004;101: Alford DP, Compton P, Samet JH. Annals Int Med 2006;144:

8 Opioid use in chronic non-cancer pain (CNCP) 5-fold increase in opioid sales in 6 years; equivalent to everyone in USA taking 700mg morphine/year Substantial increase in unintentional drug overdose deaths 60% originate from opioids prescribed within guidelines Rates of prescription painkiller sales, deaths and substance abuse treatment admissions ( ). Source: US Drug Enforcement Administration Dhalla IA, Persaud N, Juurlink DN. BMJ 2011; 343: S CDC Grand Round: Prescription drug overdoses a US epidemic.

9 Opioid use in chronic non-cancer pain (CNCP) Evidence suggests that oxycodone and hydrocodone may have higher abuse liability than morphine In Ontario, oxycodone prescriptions rose by 850% from 1991 to 2007 Deaths involving oxycodone in Ontario, Canada (and Victoria, Australia

10 Opioid use in chronic non-cancer pain (CNCP) Guidelines for safe opioid prescribing in CNCP An opioid-prescribing policy will provide guidance on prescribing which in turn facilitate a consistent response CNCP can be managed effectively in most patients with morphine equivalent dose at or below 200 mg/day; higher dosage requires careful reassessment of the pain and of risk for misuse The small-to-moderate beneficial effects of opioids for OA are outweighed by large increases in the risk of adverse events (Cochrane Review 2009) Nuesch E, et al. Cochrane Database Systematic Review 2009;4:CD ASIPP guidelines for responsible opioid prescribing in CNCP. Pain Physician 2012; 15: S1-66 Canadian guideline for safe and effective use of opioids for CNCP. April VA/DoD Clinical practice guideline for management of opioid therapy for chronic pain. May 2010

11 Management in ICU OxyContin changed back to OxyNorm and increased to 80 mg hourly, morphine PCA hourly limit unchanged iv ketamine infusion 0.2 mg/kg/hr commenced then stopped and replaced by oral methadone Methadone stopped and replaced by oral MST 40 mg BD plus sevredol PRN for breakthrough pain

12 Issues Opioid induced hyperalgesia (OIH) Opioid switching

13 Opioid induced hyperalgesia (OIH) Opioid induced hyperalgesia (OIH) opioid-induced pain sensitivity (OIPS) Enhanced pain perception in subjects receiving opioids can lead to an apparent need to increase the dose Increasing the dose of opioid may worsen the patient's condition by increasing sensitivity to pain while escalating physical dependence. An individual taking opioids who develops increased pain but cannot achieve effective pain relief despite increases in dose may be experiencing OIH OIH may be managed by switching, tapering or discontinuing opioid therapy

14 Opioid switching Opioid switching (opioid rotation) Canadian Guidelines recommend that for patients experiencing unacceptable adverse effects or insufficient opioid effectiveness from one particular opioid, a different opioid should be prescribed or therapy discontinued. Step-wise Rotation: Reduce the old opioid dose by 25-50% decrements & replace the amount removed with an equianalgesic conversion dose of the new opioid. Single-step Rotation: Stop the old opioid and start the new opioid in an equianalgesic conversion dose. NB pain may worsen if the new agent has a delayed peak analgesic effect (eg methadone)

15 Discharged to ward MST increased and eventually stopped due to twitching Recommenced OxyContin 90 mg BD plus OxyNorm Satisfied with analgesia At case conference agrees to opioid treatment plan with no escalation of regular analgesia

16 Issues Opioid treatment agreement

17 Opioid treatment agreement Opioid treatment agreements Tools for educating patients (and providers) about the opioid treatment plan and documenting the patient's agreement to participate Designed for patients with, or at risk of, aberrant behaviour Written or verbal Evidence supporting their efficacy is largely unremarkable

18 Case 2.

19 Admitted with blocked ileostomy, vomiting, abdominal sepsis and worsening of chronic abdominal pain Complex past history of ruptured appendix, bowel damage and multiple laparotomies with extensive adhesions Chronic abdominal pain managed by GP using oral oral oxycodone/naloxone (Targinact ) 30/15 mg BD Multiple drug allergies/intolerances Initial management NBM, nasogastric tube Replace targinact with fentanyl patch & im morphine For long term TPN

20 Fentanyl patch increased then removed at patient s request and replaced with Butrans patch with sl buprenorphine PRN for breakthrough pain Butrans later stopped because of skin rash and replaced with sc morphine infusion via syringe driver according to palliative care protocol

21 Issue Opioid patches Continuous subcutaneous infusion of drugs

22 Drug Reservoir-in-Adhesive Drug Matrix-in-Adhesive Characterized by the inclusion of a liquid compartment containing a drug solution or suspension separated from the release liner by a semipermeable membrane and adhesive Characterized by the inclusion of a Semisolid matrix containing a drug solution or suspension which is in direct contact with the release liner

23 Continuous sc infusions of drugs Continuous sc infusion of drugs is particularly useful in the management of malignant intestinal obstruction Breakthrough analgesia should still be prescribed Cost of delivering subcutaneous morphine by syringer driver is twice the cost of a comparable dose of sustained release tablets. NPSA safety alert (2010) identified 8 deaths and 167 non fatal incidents between 2005 and 2010 involving older ambulatory syringe drivers with rate settings based on length of liquid rather than volume Guidelines for the Use of Subcutaneous Medications in Palliative Care for Adults Primary Care and Hospices.

24 Case 3.

25 Brought in to ED following RTC (motorcycle vs car) High velocity impact to the left side of body Conscious at the scene Transferred by air ambulance No past medical history of note, no regular medications Rib fractures with small pneumothorax; chest drain inserted Closed fracture of the right femur CT scan head and cervical spine demonstrated no injuries Femoral nailing undertaken under GA Postoperative analgesia; epidural plus PCA morphine

26 Issues Regional analgesia and compartment syndrome NAP3 recommendations on duration of epidural analgesia and Red Flags AAGBI recommendations for epidural catheter removal and thromboprophylaxis medication

27 Regional analgesia and compartment syndrome Epidural for lower limb trauma is moderately controversial (compartment syndrome) Systematic review (2009) has found no convincing evidence that regional analgesia (including epidural analgesia) delays the diagnosis of compartment syndrome provided patients are adequately monitored In 32 of 35 patients classic signs and symptoms of compartment syndrome were present in the presence of epidural anaesthesia including 18 patients with documented breakthrough pain Mar GJ et al BJA 2009; 102: 3-11 Karagiannis G, Hardern R. Emergency Medicine Journal 2005; 22: 814

28 Duration of epidural analgesia Infection of the epidural space is extremely rare with an estimated occurrence from 1:10,000 to 1:100,000 patients Localised infection at the skin site is more common. Long length of epidural use (especially>4 days) is particularly associated with increased risk Guidelines? Epidurals are never kept in for more than 4 days because of the risk of infection The indications for a catheter to be retained for 7 days or more must be reviewed by the anaesthetist who inserted it Cook TM, Counsell D, Wildsmith JA. Br J Anaesth 2009; 102:

29 Epidural Red Flags Significant motor block with a thoracic epidural Unexpectedly dense motor block, including unilateral block Markedly increasing motor block during epidural infusion Motor block that does not regress when an epidural is stopped. Recurrent unexpected motor block after restarting an epidural infusion that was stopped because of motor block Discuss case with regional neurosurgical unit if any of the above Red Flags are present Cook TM, Counsell D, Wildsmith JA. Br J Anaesth 2009; 102:

30 Epidural removal and thromboprophylaxis VTE prophylaxis and timing of epidural catheter removal Unfractionated heparin Catheter removal should be delayed for 4 hours after the previous dose also check that APTT is normal Low molecular weight heparin (LMWH) Catheter removal should be delayed for 12 hours after the previous dose In both cases wait 2 hours before the next dose. Times may need to be longer for patients with renal failure as heparin undergoes renal elimination and may accumulate if renal function is poor

31 Thank you!